Case Presentation

By

Mustafa Abdelhalim FathyResident of Tropical Medicine

Minia University Hospital

Personal History

Female patient,B. A.A,25 years old,from Abu Kurkas-Al Minia,housewife,married and has one sibling 2 years old,has no special habits of medical importance

Complaint

Yellowish discolouration of the eye for 2 months.

History of present Illness

The condition has started by jaundice,of insidious onset ,very progressive course,of 2 months duration,associated with dark urine ,generalized itching all over the body,with appearance of red skin papules scattered all over the body which are characterized by scaling and peeling of the skin.

The condition is associated with diarrhea, watery in consistency mixed with mucus,yellowish in color of normal odour,of gradual onset, progressive course,not related to meals,more than 10 motions per day, affecting general condition of the patient as patient became bed ridden.

History of intermittent fever,low grade,of 1 month duration.

Patient sought dermatological advice, various topical treatment and advised for internist consultation then patient referred for admission in our department.

• No history of hematemesis,melena,epistaxis,bleeding per gums nor purpric or ecchymotic patches.

• No history of nausea,vomiting nor abdominal pain.

• No history of LL edema nor abdominal distension.

• No history suggestive of urinary troubles• No history suggestive of cardiac illness in the

form of( symptoms of pulmonary venous congestion, systemic congestion, low cardiac output, chest pain,palpitation,cyanosis,nor symptoms of embolizaion)

• No history suggestive of chest disease apart from dry intermittent cough.

• No history suggestive of neurological illness.• Patient not known to be diabetic nor

hypertensive.

Past History

• History of contraceptive injection,2 years ago.

• No history of hospital admission.

• No history surgical operation.

• No history of TB nor Bilharziasis.

• No history of traveling abroad.

• No history of trauma.

Family History

• Positive consanguinity.

• No history of similar condition.

Menstrual historyregular,D/C:4/28,average in amount, no

intermenstrual spotting

Obstetric history

2.5 months ago, patient discovered to be pregnant,although she was on contracepive injection drugs,1 week later patient suffered form massive vaginal bleeding,then patient sought obstetric consultation and diagnosed as Abortion.

The bleeding was horrible and uncontrolled,which made the patient receiving prescribed and non prescribed treatment without limitations,about 10 to 15 tablets per day,as she thought more pills,more control on bleeding.

General Examination

Patient is conscious,oriented,lies comfortable in bed.

She is not dyspnic,not orthopnic.She looks underbuilt.She looks pale and jaundiced.No cyanosisTemp 37.4 CBlood pressure 100/60 measured in supine

position Pulse 86 bpm.regular,equal on both sides,average

volume,intact peripheral pulsations,with no special character.

General Examination cont.

• No LL edema

• No palpable LN

• Generalized skin scales, areas of hyperpigmentation,erythematous rashes.

• Chest examination: NAD.

• Cardiac examination:NAD.

Abdominal Examination

• Inspection:The abdomen moves freely with respiration,

normal sub costal angle, no epigastric pulsation, no divercation of recti,umbilicus is midway between xiphi-sternum and symphysis pubis and inverted,feminine hair distribution

No visible veinsNo scar of previous operationApparent areas of scratch marks.Intact hernial orifices.

Abdominal Examination cont.

• Palpation:

Superficial:

No superficial masses, no rigidity, no tenderness.

Deep:

No palpable abdominal organs( liver,spleen,both kidneys)

Abdominal Examination cont.

Percussion

the abdomen is resonant

Liver: upper boder at 5th intercostal space

Auscultation:

Frequently auscultated intestinal sounds

Investigations

Lab:

CBC:(27/4/2015)

Hb 8 gm%(Normocytic normochromic)

TLC 12.200(lymphocytes 16%,staff 5%,neutrophils 72%,monocytes 3%,eosinophils 1%,myelocytes 1%,metamyelocytes 1%,promyelocytes 1%)

Nutrophils show toxic granulations as a sign of infection

Platlets 462.000

CBC repeated after 3 days(30/4/2015)

Hb 7.2(Normocytic normochromic)

TLC 8200(lymph 21%,neutrophils 71% monocytes7%)

Platlets 417000

Retics 6%

ESR 1st hour 105,2nd hour 136

Prothrombin concentration on admission 26%,INR 2.6

After 2 days 82%,INR 1.06

15/4/2015

• ALT 285• AST 157• Alkaline phosphatase 686• RBS 50• Sr.albumin 2 gm/dl• Total bilirubin 20 mg/dl• Direct bilirubin 17 mg/dl• Creat 0.4• Urea 26• Total protein 5.16

18/4/2015

• ALT 49• AST 35• Alkaline phosphatase 540• RBS 78• Sr.albumin 2.2• Total bilirubin 15• Direct bilirubin 5• Creat 0.53• Urea 36• Total protein 5.2

19/4/2015

• ALT 24• AST 20• RBS 83• Sr.albumin 2.5• Total bilirubin 13• Direct bilirubin 5• Creat 0.5• Urea 35• Total protein 5.2

21/4/2015 outside hospital

• ALT 32

• AST 46

• Alkaline phosphatase 985

• Total bilirubin 7.5

• Direct bilirubin 6.1

30/4/2015 outside hospital

• ALT 38

• AST 50

• Alkaline phosphatase 295

• Sr.albumin 2.6

• Total bilirubin 3.8

• Direct bilirubin 2.1

• Indirect bilirubin 1.7

• HCV Ab negative

• HBsAg negative

• HIV IgG negative

• HAV IgM negative

• Sr potassium 3.0 mmol

Abdominal ultrasound(16/4/2015)

• Liver:average size,regular surface,uniform echopattern,no IHBD or venous dilatation.

• GB:distended,thick edematous walls,with pericholecystic collection

• Both kidneys:both at Rt side(crossed fused kidneys)with no stones or backpressure changes

• Mild amount of free fluid collection

Abdominal ultrasound(21/4/2015)

The same as previous but no free fluid collection and no pericholecystic collection